Sem 4 - Case 2
A Worrying Man James Wittering, is a nurse, and a worrier. Perhaps nursing is the wrong profession for him: he has to work long and irregular hours; he eats, irregularly and whatever is to hand. He habitually grinds his teeth and he identifies too much with patients' worries. He often has tension headaches. James is aware this is not a healthy lifestyle At age 31 James begins to get indigestion - feelings of epigastric pain, nausea and epigastric fullness - which come on one to two hours after eating a meal. This occurs, after most meals, for some weeks and then disappears for some months, only to recur. This is the third period of such symptoms that James has suffered, but this time there is a deep, gnawing, steady pain as part of the indigestion. James finds that he can relieve the pain (after a delay) by eating some biscuits, drinking milk or taking antacid tablets (for example, aluminium and magnesium hydroxides) or, occasionally, by vomiting. James is referred by his GP for endoscopy and imaging, and clear evidence of duodenal ulceration is found. In discussion with the GP it becomes clear that James is worried that this will be dismissed as a ‘psychosomatic’ illness and he believes that the stress of his job caused this ulceration. However, the GP gave him an overview of the recent evidence about this issue explaining that ulcers are not in fact connected to stress, what their actual causes are and they discussed the various treatments available. Before James can start the agreed course of medication with omeprazole and antibiotics, he has a sudden agonizing pain in the mid epigastrium, accompanied by collapse. While James is in the ambulance, the pain spreads to the entire abdomen, and includes radiation to the right shoulder tip. On assessment in the Accident and Emergency (A&E) Department, James is seen to be pallid, cool and sweating, his blood pressure is abnormally low and his pulse rate is considerably elevated. He lies stiff and motionless, his abdomen immobile, the upper part rigid and tender to the pressure of the examining hand. Auscultation of the abdomen reveals no bowel sounds. About 2 hours from the start of this episode, the pain decreases somewhat, though the stiffness remains and his skin becomes warmer and pinker. This acute complication is recognised for what it was, James signs the 'Consent to Operation' form, and appropriate surgery is successfully performed within 6 hours of the onset. ILOs *To demonstrate basic knowledge of the clinical investigation of the gastro-intestinal tract *To demonstrate knowledge of gastric emptying *To demonstrate knowledge of how pain is sensed in the abdomen and the anatomical/physiological basis of referred pain *To demonstrate knowledge of lifestyle in health and disease *To demonstrate knowledge of the role of H. Pylori *To demonstrate knowledge of the anatomy, and anatomical relationships, of the abdomen and associated organs *To demonstrate knowledge of the chemical regulators of acid production *To demonstrate knowledge of the concept of stress in biological and psychological terms *To demonstrate knowledge of the epithelial lining of the stomach and duodenum and the causes and effects of ulceration *To demonstrate knowledge of the pharmacology of non-steroidal anti-inflammatory drugs, and their unwanted effects on the proximal GI tract *To demonstrate knowledge of the role of patients in regulating peptic ulcers *To demonstrate knowledge of the role of stomach secretions in digestion *To demonstrate knowledge of the secretagogue and buffering effects of food control *To demonstrate knowledge of the somatic and autonomic responses to pain and irritant stimuli *To demonstrate knowledge of the treatment of ulcers using therapeutic agents *To demonstrate understanding of the overlap between physical and psychological functioning (illustrated by anxiety) *To recognise and understand perceived stress in medical professionals *To recognise how an individual's occupation can impact health University Resources Please note that these may require you to log in to blackboard to access them. You can visit the full resource page for the case here, otherwise here are some of the main ones. Case resources *Consenting to treatment - adults with capacity - BMA's ethics tool kit *Consent guidance: patients and doctors making decisions together - GMC website *Taking an occupational history - Health, Environment, and Work website Lectures *Gastric acid secretion - Martin Steward *Decision making and consent - Soren Holm